ORIGINAL ARTICLE Septocolumellar Suture in Closed Rhinoplasty Erdem Tezel, MD, and Ayhan Numanog ˘lu, MD Abstract: Several surgeons advise a variety of tip sutures and describe their own techniques in open approach. Septocolumellar suture is one of them and can be described as a loop suture between the medial crura and caudal septum. Although some of the articles mention that it can be applied in closed rhinoplasty, there is no description of the technical details. This paper presents indications, technical steps, and advantages of the septocolumellar suture in closed rhinoplasty. After completing the classic sequence of the endonasal extramu- cous technique, the medial crural cartilages are dissected from the overlying skin at the midcolumellar level, keeping the distal fibrous attachments between the anterior columellar skin and these carti- lages intact. A 5/0 or 4/0 Prolene (Ethicon Ltd, UK) with a round needle is passed, penetrating both the medial crura and then the caudal septum. Depending on the penetration level of this suture, the tip projection can be increased or decreased, the tip can be rotated, and columellar show can be corrected. This suture also makes the medial crura of the alar cartilages and septum rigidly fixed together, thus providing stability. Depending on the experience gained in 433 primary and 62 secondary rhinoplasty cases since 2000, it can be claimed that this technique, presenting an alternative to the open approach in many cases and expanding the borders of closed approach, allows one to manipulate the tip and columella easily with closed rhinoplasty and provides a significant decrease in the subop- timal results and number of complications. Key Words: closed rhinoplasty, tip, columella, suture (Ann Plast Surg 2007;59: 268 –272) T here are numerous suture techniques described for nasal tip positioning/reshaping. One of those sutures is called “projection control suture,” 1,2 which we prefer to term as septocolumellar suture. Although several authors give differ- ent names to this suture, 1–8 the principle of the technique is the same: placing a loop suture between 2 medial crura and the caudal septum. This suture and its technical details have a place in almost all articles about open rhinoplasty. Although some of the articles mention that it can be applied in closed rhinoplasty, there is no description of the technical de- tails. 2,4,6 This paper presents indications, technical steps, and advantages of the septocolumellar suture in closed rhino- plasty. Technique The classic sequence of endonasal extramucous tech- nique is followed: bilateral intercartilaginous and transfixion incisions, skeletonization, extramucous dissection of the sep- tum, hump removal, lower lateral and upper lateral cartilage reduction, lateral osteotomies. Thus, all the steps of the classic technique are completed except mucosal sutures. Then comes the time for the preparation of the cartilages for the septocolumellar suture. The septal cartilage has already been exposed as a part of extramucous rhinoplasty. The fibroareo- lar tissue between the 2 medial crura is separated by an angulated scissors, exposing the inner surfaces of them. The columellar skin edge of the transfixion incision is held by an Adson forceps at the midcolumellar level. The medial crural cartilages are dissected from their perichondrium by the help of a fine-tip scissors (Fig. 1A). Thus, the columellar skin overlying the medial crura is separated from the lateral surfaces, but the distal fibrous attachments between the an- terior columellar skin and these cartilages are kept intact. The preparation of only the middle 4 –5 mm of the medial crura is enough to place the suture. The next step is the placement of the septocolumellar suture. A 5/0 or 4/0 Prolene (Ethicon Ltd) with a round needle is passed, penetrating the left medial crus from outside to inside manner (Fig. 1B). The needle is passed behind the columella (Fig. 1C), and then the right crus is penetrated from inside to outside (Fig. 1D). Both ends of the suture are brought out from each nostril and held together and pulled gently up and down to check out the symmetry and decide the level of the penetration of the septum by the suture. The needle is passed through the septal cartilage from right to left at this determined point (Fig. 1E). Then the suture is tied, thus bringing the medial crura to a rider position on the septum (Fig. 1F). According to the penetration level of these 3 cartilages, the following targets are achieved: 1. increasing the tip projection 2. decreasing the tip projection 3. rotation of the tip 4. correction of the columellar show and bowing 5. stabilization of the tip Received August 22, 2006, and accepted for publication, after revision, November 4, 2006. From the Department of Plastic and Reconstructive Surgery, Marmara University School of Medicine, Istanbul, Turkey. Reprints: Erdem Tezel, MD, Department of Plastic and Reconstructive Surgery, Marmara University School of Medicine, Tophaneliog ˘lu Cad. No. 13-15, Altunizade 81190, I ˙ stanbul, Turkey. E-mail: erdem@erdemtezel.com or erdemtezel@hotmail.com. Copyright © 2007 by Lippincott Williams & Wilkins ISSN: 0148-7043/07/5903-0268 DOI: 10.1097/SAP.0b013e31802e0930 Annals of Plastic Surgery • Volume 59, Number 3, September 2007 268